A randomized, controlled, double-blind trial of air insufflation versus carbon dioxide insufflation during ERCP.

BACKGROUND: Visualization during GI endoscopy requires distention of the bowel lumen. Carbon dioxide (CO(2)) insufflation decreases postprocedure abdominal discomfort and distension after colonoscopy, but there have been few published studies on its use in ERCP. OBJECTIVE: To assess the safety and efficacy of CO(2) insufflation during ERCP. DESIGN: Double-blind, controlled, randomized trial. SETTING: Tertiary-care referral center. PATIENTS: This study involved consecutive patients referred for ERCP, excluding those with known CO(2) retention or with chronic use of opiate medications. INTERVENTION: Insufflation of CO(2) versus insufflation of air. MAIN OUTCOME MEASUREMENTS: Primary outcomes were abdominal pain assessed on a visual analogue scale and abdominal distension. Secondary outcomes included transcutaneous CO(2) levels (pCO(2)) and procedural complications. RESULTS: We analyzed 74 patients, 38 in the air group and 36 in the CO(2) group. Pain scores were similar in both groups 1-hour postprocedure (16 vs 11 mm in the CO(2) and air groups, respectively; P = .29) as well as over the subsequent 24 hours. There were also no significant differences between groups in abdominal distension or pCO(2) levels. There were 13 patients with complications in the air group and 5 in the CO(2) group (P = .04; nominal significance removed by Bonferroni correction), although most complications were minor in nature. LIMITATIONS: Single-center study. CONCLUSION: The use of CO(2) for insufflation during ERCP was safe in a tertiary-care referral population. However, use of CO(2) during ERCP did not lead to decreased postprocedural pain or less abdominal distension, so its role in this procedure remains in question. NCT00685386.

Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video).

BACKGROUND: Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. OBJECTIVE: We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. DESIGN: Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING: Tertiary-care center with long-standing experience with CSEMSs. PATIENTS: Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). INTERVENTION: ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. MAIN OUTCOME MEASUREMENTS: End points were efficacy, morbidity, and clinical response. RESULTS: CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. LIMITATION: Pilot study from a single center. CONCLUSIONS: Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.